Hospital-Acquired Pneumonia (HAP) & Ventilator-Associated Pneumonia (VAP) Healthcare-Associated Pneumonia (HCAP)

Hospital-Acquired Pneumonia (HAP) & Ventilator-Associated Pneumonia (VAP) Healthcare-associated pneumonia (HCAP)
Dr. ANISH M. JOSHI

ICU REGISTRAR CRITICAL CARE DEPARTMENT
HCAP
HAP
VAP
Definitions
Healthcare-associated pneumonia (HCAP): Arises within 90 days of having been admitted to an acute care facility & pt. has resided in a nursing home or LTCF. OR Recd. I.v. antibiotics, chemo or wound care within past 30 days HAP: Arises 48 hours or more after hospital admission Is not incubating at the time of admission Ventilator-associated pneumonia (VAP): Arises 48-72 hours or more after endotracheal intubation
(American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388-416)
HAP: Impact
Incidence
Accounts for ~15% of all nosocomial infections (2nd most common cause of NIs after UTIs) Extra days in the hospital: 4-9 days Average extra days in ICU: 4.3 days In mechanically ventilated patients, the incidence increases with duration of ventilation. Approximately half of all episodes of VAP occur within the first 4 days of mechanical ventilation. The risk is estimated to be 3%/day during the first 5 days of ventilation, 2%/day during Days 5 to 10 of ventilation, and 1%/day after this.
Hospital Location & Relative Frequency of HAP & VAP

HAP
ICU
Non-ICU HAP 62.5%
ICU HAP 37.5%
VAP 86%
HAP 14%
Non-ICU HAP ICU HAP

(Kumpf G et al. J Clin Epidemiol 1998;54:495-502) (Lizioli A et al. J Hosp Infect 2003;54:141-148) (Richards MJ et al. Crit Care Med 1999;27:887-892)
VAP ICU HAP
INCIDENCE OF NOSOCOMIAL INFECTIONS IN COMBINED MEDICAL-SURGICAL ICUs

Medical Patients
Pneumonia UTI Bloodstream infection Lower resp. tract (not pneumonia) 30% 30%
Surgical Patients
Pneumonia UTI SSTI Bloodstream infection Lower resp. tract (not pneumonia) 33% 18% 14% 13% 6%
16%
6%
(Richards et al. Infect Control Hosp Epidemiol 2000;21:510-515)
Prevention
General
-effective infective control measure
staff education/hand wash/isolation
-survelliance
identify and quantify endemic and new MDR
Intubation and mechanical ventilation

-avoid if possible -non invesive whenever -orotracheal intubation and orogastric tube -continous aspiration of subglottic secretion -cuff pressure 20 mm of H20 -Circuit condensate -passive humidifier /HME -duration of intubation and ventilation -avoid constant sedation and paralysis -adequate staffing
Minimum transport of pt. Orotracheal Nasotracheal ET/RT
Aspiration
and feeding
- PUP 450 - Semirecumbent position especially when feeding -Enteral Vs Parenteral
Modulation Colonisation,antiseptic and antibiotic

-SDD -may reduce VAP /not effective when MDR -Prior antibiotic-reduce HAP/if inf in presence of antibiotic suggest MDR -Oral Chlorhexidine M/W
Other
-Stress ulcer prophylaxis Sucralfate Vs H2 Blocker -Transfusion restricted/leuckocyte depleted - Glycemic control
Risk Factors

Prior antimicrobial therapy in preceding 90 days Current hospitalisation of >5 days High frequency of antibiotic resistance in the community or in the specific hospital unit Presence of risk factors for HCAP: Hospitalisation for >2 days in the preceding 90 days Residence in a nursing home or extended-care facility Home infusion therapy (including antibiotics) Chronic dialysis within 30 days Home wound care Family member with MDR pathogen Immunosuppressive disease and/or therapy
Pathogenesis of HAP/VAP
Pathogenesis of HAP/VAP
Pathogenesis of VAP
Endogenous and Exogenous Sources
Causative Pathogens
Classification of HAP & VAP:

Risk Stratification
3 4 5 6
Time from Hospitalization (days)
Early-onset HAP
Time from Intubation (days)
Late-onset HAP
Early-onset VAP
Late-onset VAP
(American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416)
Early HAP/VAP
Bacteriology
Late HAP/VAP
S. pneumoniae H. influenzae
MSSA Susceptible GNB E. Coli Kleb. Pneumoniae Proteus spp. Enterobacter spp. Serratia marescens
P. aeruginosa Acinetobacter
MRSA Antibiotic resistant Enterobacteriaceae Enterobacter spp. ESBL +ve strains Kleb. Spp. Legionella pnemophila Burkholderia cepacia Aspergillus spp.
Higher attributable mortality and morbidity
Prognosis
Less severe, little impact on outcome Mortality minimal
(American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388-416)
Diagnosis of HAP
Diagnosis of HAP/VAP
Chest infiltrate with atleast one clinical feature

-fever -leukocytosis -purulent tracheal secretion
Noninvasive/Clinical approach
Vs.
Invasive /Quantitative culture approach
Non-invasive/Clinical
1.

CPIS (Clinical Pulmonary Infection Score)

Temperature C Points 38.5 but 38.9 1 39.0 or 36.0 2 TC, mm-3 < 4,000 or > 11,000 1 + band forms >50 % 1 Oxygenation: PaO2/FiO2, mm Hg < 250 and no evidence ARDS 2 CXR Localized infiltrate Diffuse or patchy infiltrate Progression of infiltrate Culture of tracheal aspirate Moderate or heavy growth Same pathogenic bacteria on Gram Stain 2 1 2 1
Max. Score 12 However initially when progression of infiltrate & culture report is not known max. score can be 8-10.
2.

3. 4.

5.
Most sensitive component is improvement in oxygenation
Invasive /Quantitative culture

PSB DIAGN. THRESHOLD SENSITIVITY SPECIFICITY MOST 103 66 90 SPECIFIC TRACHEAL ASPIRATE 105 TO 106
CFU/ML
BAL 104 TO 105

CFU/ML
CFU/ML
76 75 SENSITIVE
73 82 ACCURATE
More distal the sampling:
More specific but less sensitive

Lower the threshold for growth
Differential Diagnosis
Pulmonary
oedema Pulmonary Contusion & haemorrhage Pulmonary embolism Hypersensitivity pneumonitis ARDS
Initial Therapy of HAP/VAP
Management strategies summary

HAP, VAP or HCAP suspected Obtain lower respiratory tract (LRT) sample for culture (quantitative or semi-quantitative) and microscopy Unless there is both a low clinical suspicion for pneumonia and negative microscopy of LRT sample, begin empiric antimicrobial therapy using an algorithm and local microbiological data Days 2 and 3: check cultures and assess clinical response: (temperature, WBC, chest X-ray, oxygenation, purulent sputum, haemodynamic changes and organ function) Clinical improvement at 4872 hours No Cultures
Search for other pathogens, complications, other diagnoses or other sites of infection
Yes Cultures +
Adjust antibiotic therapy, search for other pathogens, complications, other diagnosis or other sites of infection
Cultures
Cultures +
De-escalate antibiotics, if possible, treat selected patients for 78 days and re-assess
Consider stopping antibiotics
ATS/IDSA Guidelines. Am J Respir Crit Care Med 2005;171:388 416
Empiric antibiotic therapy

HAP or VAP suspected (all disease severities)
Late-onset or risk factors for MDR pathogens
NO
YES
Narrow-spectrum antibiotic therapy
Broad-spectrum antibiotic therapy
ATS/IDSA Guidelines. Am J Respir Crit Care Med 2005;171:388416
Initial empiric therapy, no known risk factors for MDR pathogens, early onset and any disease severity
Ceftriaxone (2g OD ) OR Levofloxacin(750 mg OD), Moxifloxacin(400 mg OD) or Ciprofloxacin (400 mg TDS) OR Ampicillin/sulbactam( 3 g QID) OR Ertapenem (1 g OD) All i.v
Initial empiric therapy in patients with late onset or risk factors for MDR pathogens, and any disease severity
Cephalosporin OR Carbapenem OR -lactam/-lactamase inhibitor PLUS Fluoroquinolone OR Aminoglycoside
Cefepime ( 2g OD ) Ceftazidime (2 g TDS) Imipenem (500 mg QID or 1 g TDS) Meropenem ( 1 g TDS) Piperacillin/tazobactam (4.5 g QID)
Ciprofloxacin (400 mg TDS) Levofloxacin (750 mg OD)
Amikacin (20 mg/kg OD) Gentamicin or Tobramycin PLUS (7 mg/kg OD) Linezolid (600 mg/kg BD) or Vancomycin (15 mg/kg upto 1 g BD) All I.V. (if MRSA risk factors are present or there is a high incidence locally)
Factors afffecting results

Penetration ----fluroquinolone,linezolide best ----Beta lactam less Mechanism of action ---concentration dependentaminoglycoside,quinolone ---time dependent-vancomycin,Beta lactam
Post antibiotic effect for gram negative aminoglycoside,quinolone- prolong --beta lactam- no/short (except carbepenem) Beta lactam---frequent dosing Aminoglycoside,quinolone---single daily dose
Optimal antibiotic therapy
Shorten the duration from 14-21 days to 8 days unless the pathogen is not pseudomonas aeruginosa or patient has poor clinical response. Initial iv oral/enteral with good response & fning int. tract Combination therapy for MDR pathogens Cycling antibiotics within the same class may antibiotic resistance
Resolution
Microbiological --serial culture --end point-bacterial eradication,superinfection,recurrent infection,microbiological persistence --PSB -<103 cfu/ml,72 hours after starting antibiotic-Radiologicallimited value as improvement lag behind clinical detect deteriorationmultilobar,increase filtrate >50% ,cavity develop,significant pleural effusion Clinical --core temp,WBC,oxygenation
Deterioration or Nonresolution
CX
length of stay in ICU/Hosp. Expensive Necrotizing pneumonia with risk of pul. hrrage Prolonged rehabilitation due to muscle loss particluarly in elderly Death
T H A N K Y O U
Risk Factors
Co-morbid Illnesses

(contd.)
Ventilation
ICU Therapies

Injuries

Cancer COPD Chronic cardiac disease Kidney failure
CPR Corticosteroid use General surgery Neurosurgery Antacids Paralytic agents Tracheostomy RT Large-volume gastric aspiration
Burns Coma Head injury MODS ARDS
Duration of mechanical ventilation Intracuff pressure <20 cm H20 Reintubation
(Mehta RM. J Intensive Care Med 2003;18:175-88) (Patel PJ, et al. Seminar Respir Crit Care Med 2002;23:415-25) (American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416)

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Hospital-Acquired Pneumonia (HAP) & Ventilator-Associated Pneumonia (VAP) Healthcare-associated pneumonia (HCAP)

Dr. ANISH M. JOSHI

(American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388-416)

Hospital Location & Relative Frequency of HAP & VAP

Non-ICU HAP 62.5%

ICU HAP 37.5%

Non-ICU HAP ICU HAP

VAP ICU HAP

INCIDENCE OF NOSOCOMIAL INFECTIONS IN COMBINED MEDICAL-SURGICAL ICUs

(Richards et al. Infect Control Hosp Epidemiol 2000;21:510-515)

Intubation and mechanical ventilation

Minimum transport of pt. Orotracheal Nasotracheal ET/RT

- PUP 450 - Semirecumbent position especially when feeding -Enteral Vs Parenteral

Modulation Colonisation,antiseptic and antibiotic

Endogenous and Exogenous Sources

Classification of HAP & VAP:

(American Thoracic Society. Am J Respir Crit Care Med 2005;171:388-416)

Less severe, little impact on outcome Mortality minimal

(American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388-416)

Chest infiltrate with atleast one clinical feature

Invasive /Quantitative culture approach

CPIS (Clinical Pulmonary Infection Score)

Most sensitive component is improvement in oxygenation

Invasive /Quantitative culture

BAL 104 TO 105

More distal the sampling:

More specific but less sensitive

Initial Therapy of HAP/VAP

Management strategies summary

Consider stopping antibiotics

ATS/IDSA Guidelines. Am J Respir Crit Care Med 2005;171:388 416

Empiric antibiotic therapy

Late-onset or risk factors for MDR pathogens

Narrow-spectrum antibiotic therapy

Broad-spectrum antibiotic therapy

ATS/IDSA Guidelines. Am J Respir Crit Care Med 2005;171:388416

Ciprofloxacin (400 mg TDS) Levofloxacin (750 mg OD)

Factors afffecting results

Optimal antibiotic therapy

Cancer COPD Chronic cardiac disease Kidney failure

Burns Coma Head injury MODS ARDS

Duration of mechanical ventilation Intracuff pressure <20 cm H20 Reintubation

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